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Certification of Health Care Provider for Family Member’s ...

Certification of Health care Provider for department of labor Family Member's Serious Health Condition Wage and Hour Division ( Family and Medical Leave Act). _____. DO NOT SEND COMPLETED FORM TO THE department OF labor ; RETURN TO THE PATIENT. OMB Control Number: 1235-0003. Expires: 8/31/2018. SECTION I: For Completion by the EMPLOYER. INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking FMLA protections because of a need for leave to care for a covered Family member with a serious Health condition to submit a medical Certification issued by the Health care Provider of the covered Family member. Please complete Section I before giving this form to your employee.

Certification of Health Care Provider for . U.S. Department of Labor. Family Member’s Serious Health Condition (Family and Medical Leave Act) Wage and Hour Division

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  Health, Department, Family, Members, Care, Provider, Labor, Certifications, Department of labor, Certification of health care provider, Family member

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